Coroner Cites “Unhealthy Culture” at Care Firm Following Woman’s Seizure Death

A coroner identified an “unhealthy culture” at a care company after a woman with learning difficulties died at a residential home following a seizure. Holly Goodchild, 29, passed away at Cygnet House in Belton, near Great Yarmouth, on 29 March last year. At Norfolk Coroners’ Court, senior coroner Jacqueline Lake delivered a narrative ruling, stating that care plans “were not always followed by care staff,” but she was unable to make a finding of neglect. Holly’s father, Paul Goodchild, labeled the ruling “an absolute disgrace.” Management at Crystal Care, the company operating the site, informed the BBC that they had implemented “considerable changes” since her death and that the company had “moved on significantly.” Cygnet House functions as a residential home for individuals with learning disabilities, autism, and mental health needs. Ms. Goodchild was residing there, having been diagnosed with learning disabilities, personality disorder, morbid obesity, and epilepsy. The court heard that she had not taken her epilepsy medication on the day of her death and was discovered on the floor at approximately 20:00 GMT. Initially, carers did not administer first aid because they believed she was “attention seeking” and “pretending,” as revealed during the inquest. Ms. Goodchild’s medical cause of death was determined to be positional asphyxia, epilepsy, morbid obesity, and left ventricular hypertrophy. Ms. Lake noted that “many concerns” were raised in the evidence and that “an unhealthy culture which had developed at Crystal Care at the time of Holly’s death” was present. However, she stated that she would not issue a Prevention of Future Deaths report, after company director Jennifer Grego provided assurances that Ms. Goodchild’s death had been treated with seriousness. Speaking after the ruling, Mr. Goodchild told the BBC: “We lost our daughter and [we think] she could have been prevented from dying – it is disgusting.” He added: “She was beautiful, bubbly, fun, clever, cheeky, really kind, intelligent. She was a fantastic kid and I am proud to be her dad.” Her sister Karla further commented: “Just because you are in the system doesn’t mean you don’t have a right to be treated as a human.” She continued: “I just want people to know who she was and what a character she was, and I hope lessons are learnt and people get the care they should receive.” Crystal Care stated in a press release: “At the time the organisation was facing serious issues, which were reflective of the wider care sector.” The statement continued: “We continue to work closely with the Quality Assurance Team at the local authority and we remain committed to the ongoing improvements across the services.” It concluded: “Our priority is the safety and wellbeing of our service users. We express our sincere condolences to Holly’s family.” Information on Norfolk news is available via BBC Sounds, Facebook, Instagram, and X. Copyright 2024 BBC. All rights reserved. The BBC does not assume responsibility for the content found on external sites. Details concerning its approach to external linking are available.